Oconto Health and Rehab Center

Inspectors wroteBased on staff interview and record review, the facility did not report allegations of abuse and exploitation to the State Agency (SA) for 1 resident (R) (R4) of 1 sampled resident. R4 informed staff on 2/6/26 that Certified Nursing Assistant (CNA)-C stated R4 could not get out of bed for a limited amount of time. R4 also reported that CNA-C accepted a gift from R4. The allegations of abuse and exploitation were not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate allegations of abuse and exploitation for 1 resident (R) (R4) of 1 sampled resident. R4 informed staff on 2/6/26 that Certified Nursing Assistant (CNA)-C stated R4 could not get out of bed for a limited amount of time. R4 also reported that CNA-C accepted a gift from R4. The allegations of abuse and exploitation were not thoroughly investigated.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure continuous positive airway ressure (CPAP) machines were cleaned for 3 residents (R) (R1, R2, and R3) of 3 sampled residents. R1, R2, and R3 used a CPAP machines for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Staff did not clean the CPAP machines per medical orders and facility policy.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 sampled resident was free of a significant medication error. R1 was prescribed clindamycin (an antibiotic) for facial cellulitis following a hospital visit on 12/15/25. R1 missed five doses of the antibiotic when it was not available from the pharmacy. The facility did not update the physician about the missed doses. R1's wound worsened and R1 requested to be transferred to the hospital again on 12/17/25. R1's wound was irrigated, debrided, and packed. R1 received intravenous (IV) antibiotics and was discharged with wound care orders and oral antibiotics.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible. This practice had the potential to affect more than 4 of the 40 residents residing in the facility. The facility's dryers contained lint that covered approximately three-quarters of the of the bottom of the lint trap and was approximately one inch high.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a Continuous Positive Airway Pressure (CPAP) machine (which delivers a stream of oxygenated air to a person's airway) was used under a physician's order and cleaned appropriately for 1 resident (R) (R21) of 1 sampled resident. R21 used a CPAP machine. R21 did not have a physician's order to use the machine or orders to maintain and clean the machine. In addition, R21 did not have a diagnosis that supported use of the machine. Findings Include:The facility's admission Orders document, revised 5/1/25, indicates: A Physician, Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist must provide written and/or verbal orders for residents' immediate care and needs .The written and/or verbal orders should include at a minimum: a. Dietary; b. Medication orders, if indicated; c. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R38, R35, and R8) of 7 sampled residents received a pneumococcal vaccine as indicated. Upon admission to the facility, R38, R35, and R8 signed consent to receive a pneumococcal vaccine. The vaccines were not administered. In addition, a physician order to administer the vaccine was not obtained for R8.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R33) of 7 sampled residents received education regarding the risks and benefits of a COVID-19 vaccine and did not ensure the vaccine was administered. R33 requested to receive a COVID-19 vaccine. The facility did not transcribe a physician's order for the vaccine or administer the vaccine per R33's request.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R7) of 1 sampled resident. R7's physician was not updated when a reddened and painful skin area on R7's groin and scrotum worsened.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, and resolved for 1 resident (R) (R18) of 19 sampled residents. Guardian (GDN)-I (R18's court-appointed Guardian) submitted a grievance on 2/25/25 regarding concerns with cleanliness, R18's roommate, and showers. The grievance form indicated there was follow-up on 2/26/25, however, GDN-I indicated GDN-I was not updated regarding all components of the grievance and how the grievance was resolved.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R1) of 19 sampled residents. R1 indicated Certified Nursing Assistant (CNA)-E was abusive to R1. R1 reported the incident to staff. The allegation of abuse was not reported to the SA.

Inspectors wroteBased on staff and resident representative interview and record review, facility did not thoroughly investigate an allegation of abuse for 1 resident (R) (R1) of 19 sampled residents. R1 and R1's Power of Attorney for Healthcare ((POAHC)-J) reported an allegation of physical abuse to staff that involved Certified Nursing Assistant (CNA)-E. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure showers, feeding assistance, and activities of daily living (ADLs) were performed by a qualified person for 2 residents (R) (R15 and R19) of 19 sampled residents. This practice had the potential to affect more than 4 of the 41 residents residing in the facility. The facility did not ensure Hospitality Aide (HA)-D performed responsibilities that were within HA-D's scope of practice when HA-D assisted with showering, feeding, and transferring R15 and R19.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R10) of 1 resident observed during the provision of cares. R10 had an indwelling catheter and was on enhanced barrier precautions (EBP). On 3/11/25, Certified Nursing Assistant (CNA)-E and CNA-F did not wear gowns while completing personal hygiene and catheter care for R10. In addition, Registered Nurse (RN)-G did not wear a gown or complete hand hygiene between glove changes during wound care for R10.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a physician and Guardian were notified of medication refusals for 1 resident (R) (R3) of 11 sampled residents. R3 refused multiple medications in January and February of 2025. The facility did not notify R3's physician or Guardian.

Inspectors wroteBased on observation, staff and resident representative interview, and record review, the facility did not provide treatment and services to prevent weight loss and hydration for 2 residents (R) (R3 and R1) of 11 sampled residents. R3 had an order for a mechanical soft diet with ground meat. On 12/20/24, a swallow study and speech therapy evaluation was requested for a possible diet upgrade. On 12/30/24, Speech Therapy (ST) upgraded R3's diet, however, R3's diet order was not changed. As of 2/12/25, the swallow study was not completed. In addition, R3's meal intakes were not consistently documented. R1 was at risk for dehydration. Staff did not consistently document or monitor R1's fluid intake to determine if hydration interventions were effective.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to meet the needs of 2 residents (R) (R5 and R6) of 4 sampled residents. R5 did not receive calcium 200 milligrams (mg) as ordered during the AM medication pass on 2/12/25. In addition, staff did not update R5's physician regarding the missed medication. R6 did not receive Seroquel XR 50 mg as ordered during the AM medication pass on 2/12/25.

Inspectors wroteBased on resident and staff interview and record review, the facility did not allow 1 resident (R) (R2) of 3 sampled residents to set up a petty cash fund or Resident Fund Management Service (RFMS) account. R2's Corporate Guardian (CG)-H asked the facility to set up a resident account for R2. CG-H was told an account could not be set up and the facility could not cash checks for R2 unless CG-H provided direct deposit account information.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure services were provided to prevent further decrease in range of motion for 1 resident (R) (R1) of 8 sampled residents. R1's plan of care did not contain interventions to address R1's contracted left hand.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not consistently monitor nutrition/hydration intake for 1 resident (R) (R1) of 3 sampled residents. R1 had orders for one-on-one feeding assistance and meal and fluid intake to be documented each meal. Staff did not consistently document those items. In addition, R1's care plan was not updated with an intervention for staff to offer and provide R1 water every hour.

Inspectors wroteBased on staff interview and record review, the facility did not provide adequate supervision to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. On 6/8/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to a location in another city that was 37 miles from the facility. On 6/14/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to the same location. On 7/30/24, R1 left the facility and was found by police walking on a county highway that was 1.4 miles from the facility. On 8/6/24, R1 exited the facility without signing out and was found by police after 9:00 PM walking into on-coming traffic on an interstate highway off-ramp that was over 1.5 miles from the facility. [...]

Inspectors wroteBased on staff interview and record review, the facility did not provide appropriate medically-related social services for 1 resident (R) (R1) of 3 sampled residents. R1's hospital discharge summary indicated R1 had a history of a suicide attempt, was followed by a psychiatrist in the community, and had psychotropic medication discontinued while in the hospital prior to admission to the facility. The facility did not follow-up and assist R1 with the continuance of psychiatric services or attempt to expedite the guardianship process (example: request for emergency protective placement) in a timely manner when R1 left the facility multiple times and demonstrated unsafe behavior.

Inspectors wroteBased on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for background checks. The facility did not complete an out-of-state background check for Director of Nursing (DON)-B. The facility did not have a completed Background Information Disclosure (BID) form for Laundry Aide (LA)-C.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 (Human Resources (HR)-G and Certified Nursing Assistant (CNA)-F) of 3 staff reviewed for infection surveillance and 4 residents (R) (R13, R32, R23, and R189) of 14 sampled residents. This practice had the potential to affect all 35 residents residing in the facility. The facility did not complete details of a staff illness line list used for infection surveillance for HR-G and CNA-F. During an observation on 7/2/24, CNA-I did not perform appropriate hand hygiene during the provision of care for R13. During an observation on 7/2/24, R32's room contained used personal protective equipment (PPE). [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a self-administration of medication assessment was accurately completed for 1 resident (R) (R11) of 4 sampled residents. On 7/2/24, Surveyor observed medication at R11's bedside. A self-administration of medication assessment and physician's order did not accurately reflect the medications R11 was allowed to self-administer. In addition, R11's plan of care did not indicate how R11 would store and secure the medications kept in R11's room.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 1 resident (R) (R7) of 14 sampled residents. R7's PASRR Level I Screen was completed inaccurately, therefore, a PASRR Level II Screen was not completed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure comprehensive resident-centered care plans were implemented for 2 residents (R) (R7 and R15) of 14 sampled residents. On 7/2/24, Surveyor observed a bed rail on R7's bed. R7's care plan did not indicate the need for a bed rail. R15 had a history of being sexually assaulted. R15's care plan did not contain information related to R15's request for no caregivers of the opposite gender.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R21) of 14 sampled residents who required assistance with activities of daily living (ADL). Staff did not provide toenail clipping and cleaning for R21.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure medical records contained accurate and complete documentation for 2 residents (R) (R7 and R10) of 14 sampled residents. On 7/2/24, Surveyor observed a bed rail on R7's bed. R7's care plan did not indicate the need for a bed rail and R7's medical record did not contain documentation of assessments staff indicated were completed. R10's cane was taken away by staff. R10's medical record did not contain documentation of a discussion with R10 regarding the removal and under what conditions R10 could have the cane returned.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure 3 residents (R) (R1, R7, and R8) of 9 sampled residents had call lights within reach. R1, R7, and R8 were observed in their rooms without a call light within reach or a means to notify staff if assistance was needed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R1) of 9 sampled residents. In addition, the facility did not provide pharmaceutical services to ensure the safe handling of drugs and biologicals for 1 (R9) of 11 residents observed during medication administration. R1 did not receive multiple doses of hydrocortisone (a steroid medication) as ordered by R1's physician. During medication pass on [DATE], Surveyor noted slot 2 of R9's second card of buspirone (used to treat anxiety) contained a half pill that was taped in the slot. In addition, Surveyor observed Registered Nurse (RN)-C destroy a half tablet of buspirone by discarding it in the garbage.

Inspectors wroteBased on staff and resident interview and record review, the facility did not thoroughly document, investigate, or resolve grievances for 2 residents (R) (R5 and R6) of 6 residents. R5 reported Certified Nursing Assistant (CNA)-C did not change R5's clothing from the day prior. The facility did not document, investigate, or thoroughly resolve the grievance. R6 reported that R6 was wet and CNA-C ignored R6. The facility did not document, investigate, or thoroughly resolve the grievance.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R) (R1) of 3 sampled residents. On 10/2/23 at approximately 7:45 PM, R1 told Certified Nursing Assistant (CNA)-C that R2 had inappropriately touched R1 and had tried to get into R1's brief. CNA-C indicated the incident didn't happen and no action was taken. Approximately fifteen minutes later at 8:00 PM, staff heard R1 yell. Staff entered R1's closed door and observed R2, who was completely disrobed, on top of R1 and inappropriately touching R1. The facility's failure to supervise a resident who allegedly sexually abused another resident created a finding of immediate jeopardy that began on 10/2/23 at approximately 7:45 PM. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 10/19/23 at 3:15 PM. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 3 Residents (R) (R1, R2, and R4) of 3 residents reviewed for medication administration. R1 received scheduled medications outside of the facility's acceptable time frame on 9/23/23, 9/27/23, 10/2/23, 10/7/23, and 10/10/23. In addition, R1's Lidocaine Patch was not applied on 10/11/23. R2's 12:00 PM medication was administered at 1:08 PM on 10/11/23. R4's 12:00 PM medication was administered at 1:10 PM on 10/11/2.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 35 of 36 residents residing in the facility (One resident received nutrition exclusively via tube feeding.) Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Kitchen ceiling vents in the food preparation area contained visible dust. Cook (CK)-E did not wear a hairnet when CK-E entered the kitchen and began food preparation. The ice machine in the kitchen was not clean and contained a dusty filter.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 10 Residents (R) (R37, R30, R33, R21, R2, R8, R29, R24, R27, and R25) of 18 sampled residents. During an observation in the main dining, Surveyor observed dead bugs in the ceiling lights, spiderwebs in the windowsills, stained and warped ceiling tiles and noted the condition of the walls needed repair. R33 stated the condition of the dining room prevented R33 from eating in the dining room for meals. During observations and resident interviews, Surveyor noted R37, R30, R33, R21, R2, R8, R29, R24, R27, and R25's rooms contained holes in the floor, cracked floor tiles, floors that were uneven and soft and/or stained ceiling tiles. [...]

Inspectors wroteBased on observation, and staff and resident interview, the facility did not ensure privacy during pericare for 2 Residents (R11 and R24) of 16 residents reviewed. During an observation of pericare for R24, Surveyor observed a nurse open the door and enter the room on two occasions. On both occasions, the privacy curtain was open and R24 was exposed. While staff assisted R11 with bed pan use, Surveyor entered the room and noted the privacy curtain was open.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the appropriate care and services were provided to increase and/or prevent further decrease in range of motion for 1 Resident (R) (R27) of 16 residents reviewed. R27 had a leg brace to prevent contractures. The brace was not consistently offered or applied per R27's plan of care.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Nursing Assistant (NA) completed a competency evaluation for 1 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA-H was employed by the facility as a CNA, but did not complete the Nurse Aide competency exam.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not administer medications timely for 3 Residents (R) (R16, R15, and R11) of 16 residents. R16, R15 and R11 did not receive their AM medications within the facility's AM medication pass time frame on 6/3/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of a high-risk medication for 1 Resident (R) (R191) of 16 residents reviewed. R191's medical record did not contain monitoring for side effects of oxycodone (an opioid medication).